Dd Form 1172 - Application For Uniformed Services Identification Card Deers Enrollment Page 2
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2The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions , searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information
including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0020), 1215 Jefferson Davis
Highway, suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number .
PLEASE NO NOT RETURN YOUR COMPLETED FORM TO THIS ADDRESS.
RETURN COMPLETED FORM TO THE UNIFORMED SERVICE ID CARD ISSUING FACILITY .
SECTION VII - PRIVACY ACT STATEMENT
AUTHORITY:
10 U. S. C. §§ 1061 – 1065, 1072 – 1074, 1074a – 1074c, 1076, 1076a, 1077, E.O. 9397.
PRINCIPAL PURPOSE(S): To apply for the Uniformed Services Identification Card and/or DEERS Enrollment.
ROUTINE USE(S):
Information may be released to appropriate business entities, individual providers of care,
and others, on matters relating to claims adjudication, program abuse, utilization review,
professional quality assurance, medical peer review, program integrity, third party liability,
coordination of benefits, and civil and criminal litigation.
To the Department of Health and Human Services, the Department of Veterans Affairs, the
Social Security Administration, and to other Federal, state, and local gov ernment agencies
to identify individuals having benefit eligibility in another plan or program.
Applicant information is subject to computer matching within the Department of Defense or
with other Federal or non-Federal agencies. Matching programs are practiced to assure
that an individual eligible under a Federal program is not receiving duplicate benefits from
another program. A beneficiary or former beneficiary who has applied for privileges of a
Federal Benefit Program and has receiv ed concurrent assistance under another plan will
be subject to adjustment of recov ery of any improper payments made or delinquent debts
owed.
DISCLOSURE:
Voluntary; howev er, failure to prov ide information may result in denial of Uniformed
Serv ices Identification Card and/or non-enrollment in the Defense Enrollment Eligibility
Reporting System.
SECTION VIII – CONDITIONS APPLICABLE TO SPONSOR OR APPLICANT
I understand that the actions of the recipient(s) of
as to av ailability of space, facilities and the capabilities
the “ Uniformed Services Identification Card” issued as a
of the medical staff shall be conclusive.
result of this application are my responsibility insofar as
proper use of the card for benefits and privileges
Reimbursement shall be required for any unauthorized
authorized; i.e., medical and dental care, exchange,
medical care and dental care furnished at government
commissary, and morale, welfare, and recreation
expense.
Copies of regulations concerning eligibility
programs. I will cause the recipient to surrender the card
requirements are av ailable in the Service Personnel
immediately upon call to do so or when appropriate
Offices.
under applicable regulations, and will notify an agency
designated to grant authorization for privileges and
By signing this document, the sponsor or applicant
facilities in event of any change in status affecting a
certifies that he/she is aware that eligibility for benefits
recipient’ s eligibility therefor.
under the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS) terminates for all
I am aware that medical care furnished in uniformed
beneficiaries, except spouses and children of active duty
services facilities is subject to availability of space,
members, and certain disabled beneficiaries under 65,
facilities, and the capabilities of the medical staff to
when the beneficiary becomes eligible for Medicare Part
prov ide such care.
Determinations made by the
A, Hospital Insurance, through the Social Security
medical officer or contract surgeon, or his/her designee,
Administration.
PENALTY FOR PRESENTING FALSE CLAIMS OR MAKING FALSE STATEMENTS
IN CONNECTION WITH CLAIMS: FINE OF UP TO $10,000 OR
.
IMPRISONMENT FOR UP TO FIVE YEARS OR BOTH
(ACT June 25, 1948, 18 U.S. Code 287, 1001)
Designed by SS using MS Office 97, NOV 98
DD Form 1172 (BACK), SEP 96
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